Skip to main content

Antenatal History Taking


Patient Identification – Questions to Ask

1. What is your name?

(For record, consent, and communication)

2. How old are you?

(Helps assess teenage pregnancy, elderly primigravida risk)

3. What is your address?

(To know geographic risks, follow-up feasibility, socioeconomic context)

4. What is your occupation?

(To assess workload, toxin exposure, stress)

5. Are you married?

• If yes → How long have you been married?
• Helps assess infertility duration or risk of early pregnancy.

6. How many times have you been pregnant?

(You will convert this to Gravida / Para / Living / Abortions)

7. When did you come to the hospital today?

(For documentation; especially in emergency cases)

8. Do you have your antenatal card/maternity card with you?

(Confirms prior ANC & investigations)

Optional (often asked in AIIMS/Teaching hospitals):

9. What is your registration number?

(Hospital/OPD/IPD file number)

10. Who has accompanied you today?

(Checks support system)


⭐ 1. Threatened Abortion

  1. “I am having slight bleeding from the vagina.”

  2. “I have lower belly pain.”

  3. “I missed my period.”

⭐ 2. Incomplete/Complete Abortion

  1. “Heavy bleeding from the vagina.”

  2. “Severe lower stomach pain.”

  3. “Something came out from below.”

⭐ 3. Missed Abortion

  1. “My pregnancy symptoms have stopped.”

  2. “No fetal movement feeling after many days.”

  3. “Doctor said baby is not growing.”

⭐ 4. Ectopic Pregnancy

  1. “Severe lower belly pain on one side.”

  2. “Light bleeding/spotting.”

  3. “Fainting / dizziness.”

⭐ 5. Molar Pregnancy

  1. “Bleeding from the vagina again and again.”

  2. “Too much vomiting.”

  3. “Belly growing faster than normal.”

⭐ 6. Hyperemesis Gravidarum

  1. “Vomiting the whole day.”

  2. “I can’t eat or drink anything.”

  3. “Feeling very weak and dizzy.”

⭐ 7. Gestational Hypertension / Pre-eclampsia

  1. “Severe headache.”

  2. “Swelling in my feet and face.”

  3. “Blurring of vision / seeing flashes.”

⭐ 8. Eclampsia

  1. “Fits / jerking of whole body.”

  2. “Severe headache before the fit.”

  3. “Not recognizing people after the fit.”

⭐ 9. Gestational Diabetes Mellitus (GDM)

(Most come asymptomatic but common complaints:)

  1. “Feeling more thirsty than usual.”

  2. “Passing urine again and again.”

  3. “Feeling very tired.”

⭐ 10. Hypothyroidism in Pregnancy

  1. “Feeling tired all the time.”

  2. “Constipation.”

  3. “Weight gain or swelling.”

⭐ 11. Anemia in Pregnancy

  1. “Feeling tired and weak all day.”

  2. “Breathlessness on walking.”

  3. “Dizziness / feeling faint.”

⭐ 12. UTI in Pregnancy

  1. “Burning while passing urine.”

  2. “Going to pass urine again and again.”

  3. “Lower belly pain.”

⭐ 13. Pyelonephritis in Pregnancy

  1. “High fever with chills.”

  2. “Pain in the back on one side.”

  3. “Burning while urinating.”

⭐ 14. Placenta Previa

  1. “Painless bright red bleeding from vagina.”

  2. “Bleeding suddenly started without pain.”

  3. “Baby movements felt normally.”

⭐ 15. Placental Abruption

  1. “Sudden severe belly pain.”

  2. “Bleeding from the vagina.”

  3. “Baby not moving like before.”

⭐ 16. PROM (Term)

  1. “Sudden gush of water from vagina.”

  2. “Wetness continuing from below.”

  3. “Mild lower belly pain / contractions.”

⭐ 17. PPROM (Preterm Rupture of Membranes)

  1. “Water leaking from vagina before time.”

  2. “No strong pain but continuous leaking.”

  3. “Baby not due yet.”

⭐ 18. Preterm Labor

  1. “Pain coming again and again in lower belly.”

  2. “Back pain that comes in waves.”

  3. “Feeling pressure down below.”

⭐ 19. Term Labor

  1. “Pain coming every few minutes.”

  2. “Bloody mucus discharge.”

  3. “Water may leak or has leaked.”

⭐ 20. IUGR / Decreased Fetal Movement

  1. “Baby is not moving like before.”

  2. “Movements have become very less today.”

  3. “Belly not growing much.”

⭐ 21. Oligohydramnios

  1. “Baby movements feel less.”

  2. “Belly growth is slow.”

  3. “Doctor told water around baby is less.”

⭐ 22. Polyhydramnios

  1. “Belly is too big and tight.”

  2. “Breathlessness on lying down.”

  3. “Heartburn / discomfort.”

⭐ 23. Rh Negative Pregnancy (unsensitized)

  1. Usually no complaints.
    Common patient statements:

  2. “Doctor told my blood group is negative.”

  3. “I need an injection after delivery/miscarriage.”

⭐ 24. Chorioamnionitis

  1. “Foul-smelling vaginal discharge or leaking.”

  2. “Fever.”

  3. “Pain in lower belly.”

⭐ 25. Twin Pregnancy

  1. “My belly is larger than expected.”

  2. “Too much tiredness.”

  3. “More baby movements felt.”


⭐ 1. Chief Complaint: Pain Abdomen (Pregnancy)

Ask:

  1. Where exactly is the pain?

  2. When did the pain start? Sudden or gradual?

  3. Is the pain coming and going (like contractions) or constant?

  4. Intensity of pain (mild/moderate/severe)?

  5. Does the pain go to your back or thigh?

  6. Any leaking of water or bleeding per vagina?

  7. Any fever, vomiting, or burning urination?

  8. Is the baby moving normally?

⭐ 2. Chief Complaint: Bleeding Per Vaginum

Ask:

  1. When did the bleeding start?

  2. How much bleeding? (spotting / pads soaked / clots)

  3. Color of blood (bright red / dark)?

  4. Any pain in the abdomen?

  5. Any history of intercourse or trauma before bleeding?

  6. Any leaking of water?

  7. Baby movements normal?

  8. Previous episodes of bleeding?

⭐ 3. Chief Complaint: Leaking of Fluid

Ask:

  1. When did the leaking start?

  2. Was it a sudden gush or slow continuous leaking?

  3. Color and smell of the fluid?

  4. Is the leaking continuous?

  5. Any pain or contractions?

  6. Any fever? (for chorioamnionitis)

  7. Baby movements normal?

⭐ 4. Chief Complaint: Decreased Fetal Movements

Ask:

  1. Since when have you felt reduced movements?

  2. How many movements did you feel today?

  3. Have the movements suddenly decreased or gradually?

  4. Any leaking or bleeding?

  5. Any trauma/fever/headache?

  6. Previous similar episodes?

⭐ 5. Chief Complaint: Vomiting / Excessive Vomiting

Ask:

  1. How many times have you vomited today?

  2. Are you able to keep food or water down?

  3. Since when is the vomiting?

  4. Any blood in vomiting?

  5. Any dizziness or weakness?

  6. Urine output reduced?

  7. Any abdominal pain or fever?

⭐ 6. Chief Complaint: Swelling of Feet / Face

Ask:

  1. Since when have you noticed swelling?

  2. Is it increasing?

  3. Swelling more in morning or evening?

  4. Any headache, blurred vision, or flashing lights?

  5. Any pain in the upper abdomen?

  6. Any breathlessness?

⭐ 7. Chief Complaint: Headache

Ask:

  1. Where is the headache located?

  2. Since when?

  3. Severity of headache?

  4. Any blurring of vision or flashing lights?

  5. Any swelling of feet?

  6. Any seizures/fits?

  7. Any relief with medicine?

⭐ 8. Chief Complaint: Fever

Ask:

  1. Since when do you have fever?

  2. High-grade or low-grade? Continuous or intermittent?

  3. Any chills or rigors?

  4. Any burning while passing urine?

  5. Any cough or cold?

  6. Any abdominal pain or leaking?

  7. Any rash or body ache?

⭐ 9. Chief Complaint: Breathlessness

Ask:

  1. When did the breathlessness begin?

  2. On lying down or walking?

  3. Any chest pain or palpitations?

  4. Any swelling of legs?

  5. Any cough, fever, or wheezing?

  6. Previous heart/lung disease?

⭐ 10. Chief Complaint: No Fetal Movement (Suspected IUFD)

Ask:

  1. When did you last feel fetal movement?

  2. Any leaking or bleeding?

  3. Any fever?

  4. Any abdominal trauma?

  5. Any decreased fetal movements earlier in pregnancy?

⭐ 11. Chief Complaint: Gush of Water (Labor/ROM)

Ask:

  1. What time did the water break?

  2. Was it sudden or gradual?

  3. Color? (clear/green/brown/foul smell)

  4. Any contractions?

  5. Baby moving normally?

⭐ 12. Chief Complaint: Labor Pain

Ask:

  1. When did the pain start?

  2. How frequently does the pain come?

  3. How long does each pain last?

  4. Any leaking of water?

  5. Any bloody discharge (show)?

  6. Baby movements normal?

 

⭐ 1. Threatened Abortion

Hallmark feature:
➡️ Vaginal bleeding with a closed cervix
(If no bleeding → cannot call it threatened abortion.)

⭐ 2. Incomplete Abortion

Hallmark feature:
➡️ Heavy bleeding with products of conception partially expelled
(If no heavy bleeding → incomplete abortion unlikely.)

⭐ 3. Missed Abortion

Hallmark feature:
➡️ Absence of fetal cardiac activity with closed cervix AND no bleeding
(If pregnancy symptoms persist normally → less likely.)

⭐ 4. Ectopic Pregnancy

Hallmark feature:
➡️ Severe unilateral lower abdominal pain
(If no unilateral pain → ectopic unlikely.)

⭐ 5. Molar Pregnancy

Hallmark feature:
➡️ Excessive vomiting + uterus larger than gestational age
(If uterus not oversized → molar becomes less likely.)

⭐ 6. Hyperemesis Gravidarum

Hallmark feature:
➡️ Inability to retain food or fluids
(If the patient can eat/drink → it’s NOT hyperemesis.)

⭐ 7. Gestational Hypertension / Pre-eclampsia

Hallmark feature:
➡️ New-onset hypertension after 20 weeks
(If BP is normal → cannot diagnose PIH/Pre-eclampsia.)

⭐ 8. Eclampsia

Hallmark feature:
➡️ Seizure in a pregnant woman with no other cause
(If no seizure → never eclampsia.)

⭐ 9. Gestational Diabetes Mellitus

Hallmark feature:
➡️ Abnormal OGTT
(If OGTT normal → GDM ruled out, regardless of symptoms.)

⭐ 10. Hypothyroidism in Pregnancy

Hallmark feature:
➡️ Elevated TSH
(If TSH normal → primary hypothyroidism ruled out.)

⭐ 11. Anemia in Pregnancy

Hallmark feature:
➡️ Hb < 11 g/dL
(If Hb normal → anemia ruled out.)

⭐ 12. UTI in Pregnancy

Hallmark feature:
➡️ Burning urination (dysuria)
(If no dysuria → UTI very unlikely.)

⭐ 13. Pyelonephritis

Hallmark feature:
➡️ High fever with flank pain
(If no flank pain → not pyelonephritis.)

⭐ 14. Placenta Previa

Hallmark feature:
➡️ Painless bright red bleeding in late pregnancy
(If pain present → think abruption, not previa.)

⭐ 15. Placental Abruption

Hallmark feature:
➡️ Sudden, severe, painful bleeding
(If bleeding is painless → abruption unlikely.)

⭐ 16. PROM / PPROM

Hallmark feature:
➡️ Clear fluid leaking per vaginum
(If no leaking → ROM cannot be diagnosed.)

⭐ 17. Preterm Labor

Hallmark feature:
➡️ Painful uterine contractions before 37 weeks
(If no contractions → not preterm labor.)

⭐ 18. True Labor (Term Labor)

Hallmark feature:
➡️ Regular painful contractions increasing in intensity & frequency
(If contractions are irregular → false labor.)

⭐ 19. IUGR / Fetal Growth Restriction

Hallmark feature:
➡️ Symphysiofundal height < expected for gestational age
(If SFH appropriate → IUGR unlikely.)

⭐ 20. Oligohydramnios

Hallmark feature:
➡️ AFI < 5 cm / deepest pocket < 2 cm
(If AFI normal → oligohydramnios ruled out.)

⭐ 21. Polyhydramnios

Hallmark feature:
➡️ AFI > 24 cm / deepest pocket > 8 cm
(If AFI normal → polyhydramnios not possible.)

⭐ 22. Rh Isoimmunization

Hallmark feature:
➡️ Positive indirect Coombs test (ICT)
(If ICT negative → not sensitized.)

⭐ 23. Chorioamnionitis

Hallmark feature:
➡️ Fever + foul-smelling vaginal discharge/leaking
(If no fever → chorioamnionitis unlikely.)

⭐ 24. Twin Pregnancy

Hallmark feature:
➡️ Ultrasound showing ≥2 fetuses
(If USG shows one fetus → twin pregnancy ruled out.)

⭐ 25. IUFD (Intrauterine Fetal Demise)

Hallmark feature:
➡️ No fetal heart sounds on Doppler/USG
(If fetal cardiac activity present → not IUFD.)


🌟 FIRST TRIMESTER HISTORY – QUESTIONS EXCLUDING ALL NEGATIVES


1️⃣ Confirmation & Dating

  1. “How did you confirm your pregnancy? (UPT or ultrasound?)”

  2. “When did you first come to know about the pregnancy?”

  3. “When was your last normal menstrual period (LMP)?”

  4. “Were your periods regular before pregnancy?”

  5. “Was there any spotting around the time your period was due?” (This is not a negative; it's a dating-related question.)

2️⃣ Early Pregnancy Symptom Profile (Normal symptoms)

These are NOT negatives because they are expected first trimester symptoms:

  1. “Are you having nausea or vomiting?”

  2. “How many times do you vomit in a day?”

  3. “Are you able to eat and drink normally?”

  4. “Do you have breast tenderness or increased sleepiness?”

(These are positive pregnancy symptoms, not red-flag negatives.)

3️⃣ Lifestyle & Exposures (Non-negative questions)

  1. “Have you taken any medications after missing your period?”

  2. “Have you undergone any X-ray or CT scan recently?”

  3. “Do you consume alcohol, smoke, or chew tobacco?”

4️⃣ Medical Conditions Relevant to 1st Trimester

These are background risk-factor questions, NOT negatives:

  1. “Do you have thyroid problems?”

  2. “Do you have diabetes or high blood pressure?”

  3. “Do you have epilepsy or take anti-seizure medicines?”

5️⃣ First Trimester Ultrasound Questions

  1. “Have you had an ultrasound yet?”

  2. “What did the report show?”

  3. “Was a heartbeat seen?”

  4. “Did the doctor change your expected due date based on the ultrasound?”

6️⃣ Functional Assessment

These are general well-being questions, not negatives:

  1. “Are you able to do your routine work normally?”

  2. “Any significant weakness or tiredness?”


🌟 FIRST TRIMESTER – IMPORTANT NEGATIVES

(With clinical significance)

1️⃣ No bleeding per vaginum

✔ Helps rule out:

  • Threatened abortion

  • Incomplete/inevitable abortion

  • Ectopic pregnancy

  • Molar pregnancy

2️⃣ No lower abdominal pain

✔ Helps rule out:

  • Ectopic pregnancy

  • Early miscarriage

  • Corpus luteum cyst torsion

3️⃣ No unilateral abdominal pain

✔ Helps rule out:

  • Tubal ectopic pregnancy

4️⃣ No dizziness / no fainting

✔ Helps rule out:

  • Ruptured ectopic pregnancy

  • Severe dehydration from hyperemesis

5️⃣ No excessive vomiting / no inability to tolerate food

✔ Helps rule out:

  • Hyperemesis gravidarum

  • Molar pregnancy (classically has excessive vomiting)

6️⃣ No fever

✔ Helps rule out:

  • UTI / pyelonephritis

  • Septic abortion

  • Viral infections causing early pregnancy complications

7️⃣ No burning micturition (no dysuria)

✔ Helps rule out:

  • UTI

  • Cystitis

8️⃣ No increased urinary frequency / urgency

✔ Helps rule out:

  • Lower urinary tract infection

  • Worsening dehydration

9️⃣ No foul-smelling or abnormal vaginal discharge

✔ Helps rule out:

  • Vaginitis

  • Cervicitis

  • Early chorioamnionitis

🔟 No decreased urine output

✔ Helps rule out:

  • Severe dehydration (hyperemesis)

  • Acute kidney involvement

1️⃣1️⃣ No rash / joint pain / viral prodrome (optional negative if TORCH suspicion)

✔ Helps rule out:

  • Rubella

  • Parvovirus B19

  • CMV

  • Other viral illnesses damaging early pregnancy

(Include only if relevant; not mandatory for every case.)

1️⃣2️⃣ No recent radiation exposure

✔ Helps rule out:

  • Radiation-related embryopathy


🌟 SECOND TRIMESTER – QUESTIONS (NO NEGATIVES)

Second trimester (14–28 weeks) focuses on quickening, fetal growth, maternal comfort, and antenatal investigations.

1️⃣ Fetal Movement (Quickening)

  1. “Have you started feeling the baby move?”

  2. “When did you first feel the movements?”

  3. “Are the movements regular every day?”
    (These are positive questions, NOT negatives.)

2️⃣ Growth & Physical Comfort

  1. “Are you experiencing any backache?”

  2. “Any stretching or pulling sensation in the lower abdomen?”

  3. “Any difficulty in sleeping or increased tiredness?”

3️⃣ Gastrointestinal & Common Pregnancy Symptoms

  1. “Do you have acidity or heartburn?”

  2. “Any constipation?”

  3. “Any swelling of feet or hands?”
    (Asking about swelling is NOT considered a negative question; it’s part of routine symptom inquiry.)

4️⃣ Antenatal Visits & Weight Gain

  1. “How many antenatal check-ups have you had?”

  2. “Has your weight been increasing normally?”

  3. “Are you taking your iron and calcium tablets regularly?”

5️⃣ Investigations in the Second Trimester

  1. “Have you undergone the anomaly scan (around 18–20 weeks)?”

  2. “What were the findings?”

  3. “Have you done a blood sugar test (GCT/OGTT)?”

  4. “Have your hemoglobin and blood group been checked?”

6️⃣ Vaccinations

  1. “Have you received your tetanus (TT/TDAP) injection yet?”

  2. “When was the last dose taken?”

7️⃣ Fetal Wellbeing (Non-negative questions)

  1. “Have you felt the baby move more after meals?”

  2. “Do you feel the baby’s movements at the usual time each day?”

8️⃣ Lifestyle & Functional Status

  1. “Are you able to do your daily activities comfortably?”

  2. “Are you following any diet advised by your doctor?”

  3. “How is your sleep and overall energy level?”



🌟 SECOND TRIMESTER – IMPORTANT NEGATIVES

(With clinical significance)

1️⃣ No bleeding per vaginum

✔ Rules out:

  • Placenta previa (can present as mid-trimester bleeding)

  • Threatened abortion (late)

  • Cervical pathology

2️⃣ No leaking per vaginum

✔ Rules out:

  • Preterm prelabor rupture of membranes (PPROM)

  • Early chorioamnionitis

3️⃣ No pain abdomen

✔ Rules out:

  • Preterm labor

  • Abruptio placentae (rare but possible mid-trimester)

  • UTI / round ligament pathology

4️⃣ No decreased fetal movements

(By late second trimester: 20–24+ weeks)
✔ Rules out:

  • Early fetal compromise

  • IUGR

  • Oligohydramnios

  • Fetal demise (IUFD)

5️⃣ No swelling of feet / no sudden swelling

✔ Rules out:

  • Gestational hypertension

  • Pre-eclampsia

6️⃣ No severe headache / visual disturbances

✔ Rules out:

  • Pre-eclampsia

  • Imminent eclampsia

7️⃣ No fever

✔ Rules out:

  • Chorioamnionitis

  • Viral illness

  • UTI / pyelonephritis

8️⃣ No burning micturition

✔ Rules out:

  • UTI (very common in 2nd trimester)

  • Pyelonephritis risk

9️⃣ No abnormal vaginal discharge

✔ Rules out:

  • Bacterial vaginosis (linked to preterm labor)

  • Candidiasis

  • Cervicitis

🔟 No abdominal trauma

✔ Rules out:

  • Placental abruption risk

  • Fetomaternal hemorrhage

1️⃣1️⃣ No excessive weight gain / no rapid weight gain

✔ Rules out:

  • Pre-eclampsia (fluid retention)

  • Fluid overload / edema of pregnancy


🌟 THIRD TRIMESTER – QUESTIONS (NO NEGATIVES)

The third trimester focuses on fetal movements, labor symptoms, maternal wellbeing, monitoring, and antenatal investigations.

1️⃣ Fetal Movement Pattern

  1. “Are you feeling the baby’s movements regularly?”

  2. “Do you feel the baby moving at the usual times of the day?”

  3. “Have the movements become stronger or more frequent as pregnancy progressed?”

(These are positive questions, not negatives.)

2️⃣ Symptoms of Onset of Labor

  1. “Have you been experiencing any uterine tightening or contractions?”

  2. “Do these tightenings come at regular intervals?”

  3. “Have you noticed any mucous discharge (‘show’)?”

  4. “Have you felt any trickling or gush of fluid from the vagina?”
    (Asking about leaking here is allowed because it is a labor-related question, not a negative in third trimester history.)

3️⃣ Physical Discomforts of Late Pregnancy

  1. “Are you having backache or pelvic pressure?”

  2. “Any difficulty in walking or standing for long?”

  3. “Any trouble sleeping due to the size of the abdomen?”

4️⃣ Gastrointestinal & Respiratory Symptoms

  1. “Do you have heartburn or indigestion?”

  2. “Any constipation?”

  3. “Any breathlessness on lying down or during activity?”

5️⃣ Antenatal Follow-up

  1. “Have you been coming for regular antenatal check-ups?”

  2. “Has your weight been increasing appropriately?”

  3. “Are you taking your iron, calcium, and other prescribed supplements regularly?”

6️⃣ Investigations & Monitoring

  1. “Have you had a growth scan in the third trimester?”

  2. “What did the ultrasound report say about the baby’s growth and the amniotic fluid?”

  3. “Have you undergone a non-stress test (NST)?”

  4. “Have your hemoglobin and blood sugar been rechecked?”

7️⃣ Vaccination & Prophylaxis

  1. “Have you taken your tetanus/TDAP dose for this trimester?”

  2. “When was the last dose given?”

8️⃣ Previous Obstetric Interventions

  1. “If you had a previous C-section, what instructions were you given for mode of delivery this time?”

  2. “Have you discussed birth planning with your doctor?”

9️⃣ Functional & Daily Life Questions

  1. “Are you able to do your routine activities comfortably?”

  2. “Do you get tired more easily now?”

  3. “How is your sleep?”


🌟 THIRD TRIMESTER — IMPORTANT NEGATIVES

(With clinical significance)

1️⃣ No decreased fetal movements

✔ Rules out / makes unlikely:

  • Fetal distress

  • IUGR

  • Oligohydramnios

  • Placental insufficiency

  • IUFD (intrauterine fetal demise)

2️⃣ No bleeding per vaginum

✔ Rules out:

  • Placenta previa

  • Placental abruption

  • Preterm labor with bloody show (if early in 3rd tri)

3️⃣ No leaking per vaginum

✔ Rules out:

  • PROM (prelabor rupture of membranes)

  • PPROM

  • Early chorioamnionitis

4️⃣ No regular painful contractions

✔ Rules out:

  • Preterm labor (if <37 weeks)

  • False labor vs early labor

  • Uterine irritability from infections

5️⃣ No severe headache / no visual disturbances

✔ Rules out:

  • Pre-eclampsia (severe features)

  • Imminent eclampsia

6️⃣ No swelling of feet / no sudden generalized swelling

✔ Rules out:

  • Pre-eclampsia

  • Severe anemia–related edema

  • Renal dysfunction

7️⃣ No right upper abdominal pain / epigastric pain

✔ Rules out:

  • Severe pre-eclampsia

  • HELLP syndrome

  • Acute fatty liver of pregnancy

8️⃣ No fever

✔ Rules out:

  • Chorioamnionitis (especially with PROM)

  • Viral infections

  • Pyelonephritis

9️⃣ No burning micturition

✔ Rules out:

  • UTI (very common in late pregnancy)

  • Cystitis

  • Pyelonephritis risk

🔟 No breathlessness at rest / no orthopnea

✔ Rules out:

  • Peripartum cardiomyopathy

  • Severe anemia

  • Pulmonary edema (from pre-eclampsia)

1️⃣1️⃣ No severe back pain or abdominal trauma

✔ Rules out:

  • Abruption risk

  • Musculoskeletal injury

  • Fetomaternal hemorrhage


🌟 MENSTRUAL HISTORY – QUESTIONS TO ASK

1️⃣ Basic Cycle History

  1. “When was your last menstrual period (LMP)?”

  2. “Were your periods regular before pregnancy?”

  3. “What was your usual cycle length?”

  4. “How many days did your bleeding last normally?”

2️⃣ Flow and Pattern

  1. “Was your flow normal, scanty, or heavy?”

  2. “Did you pass any clots during your periods?”

  3. “Did you require more pads than usual?”

3️⃣ Pain and Associated Symptoms

  1. “Did you have pain during your periods?”

  2. “Was the pain mild, moderate, or severe?”

  3. “Did pain interfere with your daily activities?”

4️⃣ Intermenstrual & Post-coital Symptoms

  1. “Did you ever have bleeding between periods?”

  2. “Did you have bleeding after intercourse?”

5️⃣ Age-related Questions

  1. “At what age did your periods start (menarche)?”

  2. “Have you ever missed periods before this pregnancy?”

6️⃣ Contraception / Recent Cycle

  1. “Were you using any contraception before this pregnancy?”

  2. “Did you have regular cycles up until the last period?”

7️⃣ Menopausal Screening (only if relevant)

  1. “Have your periods stopped permanently?”

  2. “If yes, at what age?”


🌟 OBSTETRIC HISTORY (PREVIOUS PREGNANCIES) — QUESTIONS TO ASK

You must ask these questions for EACH previous pregnancy (G1, G2, G3…).

1️⃣ Basic Pregnancy Details

  1. “In which year did this pregnancy occur?”

  2. “How many months did your pregnancy continue?”

  3. “Was it a full-term or preterm pregnancy?”

2️⃣ Antenatal Period

  1. “Did you have any problems during that pregnancy?”

  2. “Any high blood pressure or swelling?”

  3. “Any sugar problem (diabetes) diagnosed then?”

  4. “Any bleeding or pain during the pregnancy?”

  5. “Did you take regular antenatal check-ups?”

3️⃣ Onset & Course of Labor

  1. “Did your labor start on its own or was it induced?”

  2. “Did your water break before labor?”

  3. “How long did the labor last?”

4️⃣ Mode of Delivery

  1. “How was the baby delivered — normal, forceps/vacuum, or cesarean?”

  2. “If cesarean, what was the reason?”

5️⃣ Baby Details

  1. “What was the baby’s birth weight?”

  2. “Was the baby active and crying at birth?”

  3. “Did the baby need NICU admission?”

  4. “Did the baby have any health problems?”

6️⃣ Outcome of Pregnancy

  1. “Was the baby born alive or was it a stillbirth?”

  2. “If alive, is the child healthy now?”

  3. “Any neonatal death? If yes, after how long and why?”

7️⃣ Puerperium (Post-delivery period)

  1. “Did you have any complications after delivery?”

  2. “Any fever, excessive bleeding, or infection?”

  3. “Did your stitches heal properly?”

  4. “Were you able to breastfeed normally?”

8️⃣ Special Points

  1. “Did you receive anti-D injection in any pregnancy?” (if Rh-negative)

  2. “Any history of twins?”

  3. “Any history of abortion or miscarriage?”


🌟 POSTPARTUM CASE — QUESTIONS (NO NEGATIVES INCLUDED)

(Use this for ward rounds, exams, and AIIMS-style case taking.)

1️⃣ Basic Delivery Details

  1. “When did you deliver?”
  2. “Was it a normal delivery, assisted delivery, or cesarean section?”
  3. “What was the reason for induction or cesarean, if done?”
  4. “Where did you deliver (hospital/home)?”

2️⃣ Labor & Delivery Course

  1. “Did your labor start on its own or was it induced?”
  2. “How long was your labor?”
  3. “Did your water break before or during labor?”
  4. “Was any instrument (forceps/vacuum) used?”

3️⃣ Baby Details

  1. “What is your baby’s sex?”
  2. “What was the baby’s birth weight?”
  3. “Was the baby crying and active at birth?”
  4. “Did the baby require NICU admission?”
  5. “Is the baby feeding well now?”

4️⃣ Immediate Postpartum Period

  1. “How were you feeling in the first 24 hours after delivery?”
  2. “Did you pass urine normally after delivery?”
  3. “When did you pass stools after delivery?”
  4. “Did you get up and walk comfortably after delivery?”

5️⃣ Lochia (Postpartum Bleeding)

  1. “What is the amount of bleeding you are having now?”
  2. “What is the color of the discharge?”
  3. “Has the bleeding been reducing over days?”

6️⃣ Breast & Feeding History

  1. “Have your breasts become full or firm since delivery?”
  2. “Are you breastfeeding your baby?”
  3. “How often does the baby feed?”
  4. “Any difficulty in positioning or latching?”

7️⃣ Pain & Wound Healing (Non-negative questions)

(These are positive questions and not considered “negatives.”)
25. “Do you have any pain at the stitches site?”
26. “Are your stitches (perineal/cesarean) healing well?”
27. “Are you able to move comfortably?”

8️⃣ General Well-being

  1. “How is your appetite?”
  2. “Are you able to sleep well?”
  3. “Do you feel emotionally stable after delivery?”
  4. “Do you have support at home for baby care?”

9️⃣ Postpartum Check-ups and Advice

  1. “Have you been examined after delivery by your doctor?”
  2. “Were you given any medicines to continue at home?”
  3. “Have you received advice about contraception?”
  4. “Have you started any contraception yet?”


🌟 POSTPARTUM IMPORTANT NEGATIVES

(With clinical significance)

1️⃣ No excessive bleeding / no heavy lochia

✔ Rules out:

  • Postpartum hemorrhage (primary or secondary)
  • Retained products of conception
  • Uterine atony
  • Subinvolution of uterus

2️⃣ No foul-smelling vaginal discharge

✔ Rules out:

  • Puerperal sepsis
  • Endometritis

3️⃣ No fever / no chills

✔ Rules out:

  • Puerperal sepsis
  • Mastitis/breast abscess
  • Urinary tract infection
  • Wound infection

4️⃣ No abdominal pain / no lower abdominal tenderness

✔ Rules out:

  • Endometritis
  • Retained products of conception
  • Infection extending to parametrium

5️⃣ No burning micturition / no difficulty passing urine

✔ Rules out:

  • UTI
  • Cystitis
  • Urinary retention (common after prolonged labor or epidural)

6️⃣ No urinary incontinence

✔ Rules out:

  • Pelvic floor injury
  • Vesicovaginal fistula (later presentation)

7️⃣ No wound pain / no wound discharge

(Perineal episiotomy or cesarean wound)
✔ Rules out:

  • Wound infection
  • Wound dehiscence
  • Hematoma

8️⃣ No breast pain / no redness of breast

✔ Rules out:

  • Mastitis
  • Breast abscess
  • Engorgement complications

9️⃣ No calf pain / no leg swelling

✔ Rules out:

  • Deep vein thrombosis (major postpartum risk)

🔟 No severe headache / no blurred vision

✔ Rules out:

  • Postpartum pre-eclampsia
  • Imminent eclampsia
  • Post-dural puncture headache

1️⃣1️⃣ No shortness of breath / no chest pain

✔ Rules out:

  • Pulmonary embolism
  • Peripartum cardiomyopathy
  • Pulmonary edema

1️⃣2️⃣ No inability to breastfeed / no poor milk output

✔ Rules out:

  • Lactation failure
  • Engorgement
  • Hormonal insufficiency
  • Infant feeding issues


7. Past Medical History

  • Hypertension, Diabetes

  • Heart disease

  • TB, Asthma

  • Thyroid disorders

  • Seizure disorder

  • HIV, hepatitis, STDs

8. Past Surgical History

  • Any abdominal or pelvic surgery (myomectomy, LSCS, laparoscopy)

  • Blood transfusions

  • Anesthesia complications

9. Family History

  • Twins

  • Hypertension/diabetes

  • Genetic disorders

  • Congenital anomalies

  • Pre-eclampsia in mother/sisters

10. Personal History

  • Diet (veg/non-veg), calorie intake

  • Sleep

  • Bowel/bladder habits

  • Substance use (tobacco/alcohol)

  • Domestic violence or stress

11. Drug & Allergy History

  • Current medications

  • Allergies to drugs/food/latex

12. Socioeconomic & Environmental History

  • Living conditions

  • Support system

  • Access to healthcare

  • Financial condition


Comments

Post a Comment